Registration Form 3935 Enright Avenue

Pamoja Prep

Academy

Registration Form 3935 Enright Avenue

St. Louis, Mo 63108

Phone: (314) 533-0894

Applicant's (Student) Full Name: ______

Parent's Full Name: ______Relationship______

Guardian:______Relationship______

Home Address: ______

City______State______Zip______

Home Phone: ______Work Phone: ______

Cell Phone: ______

Languages Spoken at home: ______

Grade Level Student will be attending______

Present Age: ______DOB:______

Gender: ___ M ___ F

______

Does your child have any health problems or allergies?

______

Pamoja Prep

Academy

Registration Form 3935 Enright Avenue

St. Louis, Mo 63108

Phone: (314) 533-0894

Has your child been immunized? If so please attach most recent immunization forms or letter requesting waive.

______

Parent's Status: ___ Married ___ Domestic Partners ___ Separated ___ Divorced ___ Single ___ Widowed

First Parent's Name: ______

First Middle Last

What does your child call this parent? ______

Home Address (if different): ______

______Gender: ___ M ___ F

Home Phone: ______Cell Phone: ______

Name & Address of Employer: ______

______

Occupation/Position: ______

Business Phone: ______Fax: ______E-Mail: ______

Second Parent's Name: ______

First Middle Last

Pamoja Prep

Academy

Registration Form 3935 Enright Avenue

St. Louis, Mo 63108

Phone: (314) 533-0894

What does your child call this parent? ______

Home Address (if different): ______

______Gender: ___ M ___ F

Home Phone: ______Cell Phone:______

Name & Address of Employer: ______

______

Occupation/Position: ______

Business Phone: ______Fax: ______

E-Mail: ______

Sibling's Name: ______Age: ____ Gender: ____ School: ______

Health Insurance Information:

Is your child under any medical insurance plan?______

What is the medical carrier name?______

Type of Plan ____PPO _____HMO ______POS _____Other

Who is the primary subscriber (Name) of the plan?______

Pamoja Prep

Academy

Registration Form 3935 Enright Avenue

St. Louis, Mo 63108

Phone: (314) 533-0894

Emergency Contact Information:

In the event of a medical emergency, I give Pamoja Prep Academy and the agents that represent the institution the right to take my child to the nearest hospital or urgent care facility to service medical issues that are deemed urgent.

______

Parent Print NameParent Signature

______

Parent Print NameParent Signature

In the event of an emergency, I authorize the following adults to be contacted if I can not be reached.

______